vaginal prolapse
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  • 1. Management Of Genital Prolapse Associate Professor Semyatov S.M. Department of Obstetrics and Gynecology with course Perinatology Peoples’ Friendship University of Russia, Moscow
  • 2. DEFINITION Prolapse/Procidentia is downward decent of uterus &/or vagina. (Procidentia is from Latin procidere - to fall). It is a state of pelvic relaxation due to a disorder of pelvic support structures that is, the endopelvic fascia. It is not a disease but a disabling condition.
  • 3. CAUSE
    • WEAKNESS OF THE SUPPORTS OF THE UTERUS & VAGINA
    • Precipitating / Exaggerating / Unmasking Causes -
      • INCREASED INTRA ABDOMINAL PRESSURE
        • Chronic cough
        • Chronic Constipation
        • Heavy Wt.Lifting / domestic Work
        • Obesity, Ascitis
      • WEAKNESS OF THE SUPPORTS & MUSCLES
        • Chronic ill health, malnutrition dysentery, anemia
        • Inadequate rest during pureperium
        • Menopause
  • 4. TYPES OF PROLAPSE
    • Vaginal
    • Anterior –cystocele & urethrocele
    • Posterior - Enterocele & Rectocele
    • Vault Prolapse - a special term applied to the prolapse of upper vagina
    • Uterine/Utero-vaginal- Acquired or Congenital.
      • First degree.
      • Second degree &.
      • Third degree-(total Prolapse / complete procidentia).
    • However Procidentia is often used only to denote third degree uterine prolapse.
  • 5. EFFECTS OF PROLAPSE
    • NO SYMPTOM- mild & moderate prolapse.
    • Discomfort & disability.
    • Sexual Dysfunction.
    • URINARY- Frequency, Dysuria, Stress incontinence, infection.
    • Incomplete emptying of rectum.
    • Discharge.
    • Backache.
    • Ulceration & Infection.
  • 6. WHEN TO TREAT ?
    • Should be treated only when it is symptomatic (Be certain symptoms are due to Prolapse )
    • Interferes with the normal activity of the woman
    • The patient seeks treatment
  • 7. HOW TO TREAT ?
    • NON-SURGICAL Methods: -Limited Role
      • PELVIC FLOOR REHABILITATION (pelvic muscle exercises, galvanic stimulation, physiotherapy, rest in the purperium).
      • HORMONE REPLACEMENT, both systemic and local.
      • PESSARY TREATMENT for temporary relief
        • During Pregnancy, Puerperium & Lactation
        • When Operation is Unsafe due to Extreme Senility/Debility and Diseases
        • Preoperatively
        • For therapeutic test
  • 8. HOW TO TREAT ?
    • SURGICAL TREATMENT: - RECONSTRUCTIVE SURGERY is invariably needed and has to be a COMBINATION OF PROCEDURES to correct the multiple defects.
  • 9. SURGICAL TREATMENT
    • It is the definitive & curative treatment of Prolapse.
    • It is a cold operation. So complete investigation should be done & all existing diseases & disorders should be treated first.
    • Pre operative pessary/tampoon & or Hormone treatment should be given as indicated.
    • Meticulous and through examination under anaesthesia should be done before deciding the surgery.
  • 10. SURGICAL TREATMENT
    • Depending on the type & extent of Prolapse, surgery should be tailor made not only to rectify the defect but also to suit the individual patient’s requirement.
    • Absolute haemostasis is mandatory. Diathermy should be liberally used.
    • Vaginal suturing should be with interrupted stitches. Synthetic absorbable fine sutures are preferable.
    • Catheter for more than 48 hrs should be exceptional.
    • Strict antibiotic prophylaxis is essential
  • 11. VAGINAL OPERATIONS FOR PROLAPSE
    • Anterior colporrhaphy
    • Posterior colporrhapry- High / Low
    • Enterocele repair
    • Perineorrhaphy
    • Amputation of cervix
    • Paravaginal repair
    • Hysterectomy with or without Colporrhaphy / Perineorrhaphy
  • 12. VAGINAL OPERATIONS FOR PROLAPSE
    • Manchester/ Fothergill’s operation & Shirodkar’s modification
    • Uterus/Cervix suspension/fixation
    • Vaginal vault suspension/fixation
    • Retro-rectal levatorplasty and post. anal repair for associated rectal prolapse
    • Vaginectomy ?
    • Colpocleisis ?
  • 13. Anterior colporrhaphy & Urethroplasty
    • For correction of Cystocele & Urethrocele
    • Incision- Midline / Inv.T / Elliptical
    • Excision of vagina according to the size & site of laxity
    • Avoid shortening &/or narrowing of vagina
    • Closure with interrupted sutures
  • 14. Posterior colporrhaphy & Enterocele repair
    • For correction of Enterocele & Rectocele
    • Enterocele repair can be done either by vaginal or abdominal route depending on the associated procedures.
    • Approximation of uterosacral ligaments for enterocele & prerectal fasciae and levator for rectocele with interrupted sutures is essential
    • Excision of vagina should be tailor made
    • Perineorrhapy to be done only if perineal body is torn
  • 15. Perineorrhaphy
    • Not an Operation for prolapse, but Indicated only for associated old 2nd degree perineal tear
    • Performed along with posterior colporrhaphy
    • Aim-Reconstruction of the Perineal body and reduction of gaping introitus.
    • Can cause Dyspareunea
    • Essential steps - Excision of the scar tissue & approximation of levator ani & superficial perineal muscles
  • 16. Vaginal Hysterectomy with/without Vaginal repair
    • Indicated when uterus needs removal, in old age & in total prolapse.
    • Patient’s consent is mandatory knowing that there are alternatives to hysterectomy.
    • Usually combined with Ant. & Posterior colporrhaphy.
    • Perineorrhaphy is not mandatory but case specific.
    • Vault suspension is an essential step.
    • If sexual function is not needed narrowing of vaginal canal should be done.
  • 17. Amputation of cervix
    • Not for Prolapse.Indicated only for cervical elongation (Uterocervical length >12.5 Cm )
    • To be done only as a part of Fothergill’s repair/sling operations.
    • Adequate cervical dilatation - a prerequisite
    • Bladder displacement is a must
    • Excision of cervix should not exceed 2 cm
    • Likely to affect reproductive life
    • Long-term complications are real risks
  • 18. Fothergill’s operation
    • It is the operation of choice in uncomplicated Utero-vaginal prolapse when uterus is to be preserved but NO future child bearing is required.
    • It is a combination of, Amp. of Cx., Fixation of the Meconrodt’s ligament to the anterior of Cx. & Ant. Colporrhaphy. D&C is a must.
    • Post. Colporrhaphy to be performed only if Ent/Rectocele is present
    • Perineorrhaphy is usually not required
  • 19. Fothergill’s operation
    • Not useful if ligaments are weak & Uterus is of normal size. Purandare’s modification may help.
    • Technically difficult operation, requiring high degree of surgical skill.
    • Threat of short-term complications.
    • Real possibilities of long term complications.
    • Recurrence/Failure.
    • Sling operations are better alternatives
    • HAS A BLEAK FUTURE
  • 20. ABDOMINAL OPERATIONS FOR PROLAPSE
    • Sling operations
    • Closure or repair of enterocele
    • Sacrocolpopexy
    • Anterior Colpopexy
    • Colposuspension
    • Paravaginal repair
  • 21. Abdominal Sling operations
    • Indicated when the ligaments are extremely weak as in nullipara & young women.
    • Preserves reproductive function.
    • Principle - With a fascial strip / prosthetic material (Merselene tape or Dacron) the Cx is fixed to the abdominal wall / sacrum / pelvis.
    • Amp.of Cx should also be done if Utereocervical length >12.5cm.
    • Cystocele/Rectocele repair if needed can be done vaginally before or after.
    • Enterocele repair can also be done abdominally.
  • 22. Abdominal Sling operations
    • It is a major abdominal operation & Synthetic material is costly & not widely available in India.
    • Types-.
      • Shirodkar’s posterior sling.
      • Purandare’s anterior cervicopexy.
      • Khanna’s sling.
      • Virkud’s composite sling.
  • 23. Shirodkar’s sling
    • Tape is fixed to the post. Aspect of isthmus & sacral promontory
    • Anatomically most correct but difficult to perform
    • Risks of complication
  • 24. Purandare’s cervicopexy
    • Tape is anchored to the ant.aspect of isthmus and ant. abd. Wall
    • Easy to perform
    • Dynamic support
  • 25. Virkud’s composite sling operation
    • Tape is anchored from the post aspect of isthmus to sacral promontory on the Rt. side & ant. abd. Wall on the Lt. Side
    • Utrosacral ligament is plicated
    • Technically easy
  • 26. Khanna’s sling operation
    • Tape is anchored to ant aspect of isthmus & ant. sup. Iliac spine
    • Easier to perform and safer
    • But tape is superficial
    • Risk of infection
  • 27. Abdominal Colpopexy / Colposuspension
    • Indicated when vault prolapse occurs after hysterectomy or vaginal laxity is to be corrected at abdominal hysterectomy.
    • Major abdominal operation & technically difficult.
    • Sexual function is preserved.
    • Methods-.
      • Sacrocolpopexy.
      • Ant.Colpopexy.
      • Colposuspension.
  • 28. Sacrocolpopexy
    • Vault is fixed to 3rd & 4th sacral vertebrae with a facial strip / proline mesh under the peritoneum to the right of rectum
    • Enterocele repair can be done if required
  • 29. Ant.Colpopexy
    • Corrects ant. vag laxity & stress inc.
    • Useful at abdominal hysterectomy / for vault prolapse.
    • Extra peritoneal supra pubic approach if done alone.
    • Enterocele repair i f required.
    • Vagina stitched to the i leo-pectineal ligaments.
  • 30. Vault / Colposuspension
    • Vault is fixed to the abdominal wall by a facial strip or merseline tape
  • 31. LAPAROSCOPIC SURGERY PROLAPSE
    • Advantages of M I S -small incision, better view, haemostasis, no packing, minimal tissue & bowel handling, short recovery, less pain, insignificant scar
    • Can all types of prolapse be treated?- Yes.
    • Ant. / Post. Lower vaginal repairs if needed can also be done vaginally before or after lap.Surgery
    • However extended period of rest is essential
    • Expertise is needed
    • Presently cannot be widely practised
    • This is the surgery of the future today
  • 32. LAPAROSCOPIC SURGERY PROLAPSE
    • PROCEDURES:-
      • Cervicopexy / Sling operations with/without Lap.Paravaginal repair / Vaginal repair
      • VH / LAVH / LH / TLH + Colposuspension
      • VH / LAVH /LH/TLH+ Lap.Pelvic reconstruction
      • Rectocele repair & levatorplasty
      • Enterocele repair with suturing of uterosacral ligaments
      • Colpopexy- Ant / Post
  • 33. Laparoscopic Cervicopexy/sling Operations
    • All types of sling operations can be better performed by laparoscopy
    • Associated vaginal prolapse can also be repaired laparoscopically (Lap.Paravaginal repair)
    • Vaginal Ant./Post. colporrhaphy can be done before / after laparoscopy
  • 34. Laparoscopic Vault suspension/ Culdoplasty)
    • Can be done with VH / LAVH / LH / TLH
    • Corrects mild laxity
    • Prevents vault prolapse
  • 35. Laparoscopic Pelvic Reconstruction With VH / LAVH / LH / TLH
    • An alternative to Ward- Mayo’s operation
    • Before Hys., Lap.Ureteral dissection is done and suture placed in uterosacral ligament near sacrum & left long, for latter vaginal vault suspension
    • Lap. levator plication if needed
    • Enterocele repair and suturing of uterosacral ligaments if needed
    • Retro pubic Colposuspension (Bruch) if required
  • 36. Laparoscopic Rectocele repair & Levatoroplasty
    • Rectovaginal space is opened & rectum dissected
    • Interrupted sutures given in the levator in the midline
    • Enterocele repair done if indicated
    • Vaginal vault suspension done
  • 37. Laparoscopic Enterocele repair
    • Rectovaginal space is opened, sac excised and purse string suture given
    • Uterosacral ligament sutured
  • 38. Laparoscopic Post Colpopexy / Sacrocolpopexy
    • Indicated for vault prolapse
    • Enterocele if present is first repaired
    • Prolene mesh is fixed to the vault & 3rd-4th sacral vertebrae, under the peritoneum in the R t. p ara rectal space
  • 39. Time has come for Laparoscopic Surgery for Prolapse So move with the times. Practice laparoscopy. This is the Surgery of the future today. THANK YOU